Appeal Denied
I received my denial letter in yesterday mail. Here is what it states:
(And, yes, I HAVE already mailed off a request for a hearing.... The board meets quarterly. Next meeting is end of October)
Dear Mrs. ________:
The Appeals Committee for (my insurance company) recently met to consider your request for coverage of gastric bypass revision surgery/duodenal switch procedure. The Committee relied on the medical review information presented and took action to uphold the denial of coverage of these procedures. This is based on the Plan’s Exclusions and Limitations, listed on pages 36 and 37, which state:
Services which are primarily for weight-loss (except surgery for morbid obesity which has received prior authorization from the Administrative Office); and
Any medical services which are not medically necessary (see page 71).
The January 2010 Summary Plan Description is enclosed for your reference. If you apply for benefits and are ruled ineligible, or if you did not receive the full amount of benefits to which you are entitled, or if you are otherwise adversely affected by any action of the Trustees, you have the right to appeal to and request the Board of Trustees to conduct a hearing in the matter. Such a request must be in writing and submitted to the Trust’s Administration Office within one hundred and eighty (180) days after the date of mailing to you of notification of such ruling or decision. The full Board will then conduct a hearing at which you will be entitled to present your position and any evidence in support thereof. You may be represented at any such hearing by attorney or by any other representative of your choosing. Thereafter, the Trustees will issue a written decision reaffirming, modifying or setting aside the former action.
Sincerely,
Blah Blah Blah
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
I am so sorry ! I won at hearing level... so hang in there ! Many have had to go to that level to win. Keep on fighting, as you know it will be worth it !
Ginger<><
Revision #2 Dr John Rabkin June 21, 2013; First Revision DS - Dr Maguire 5-18-09; First DS 7-15-2003 Dr Clark Warden = Third time is the charm 
Thank You, Ginger!!!!!
I am hanging in there, but, more waiting!!!!! Oh well, if anything I have learned to deal with the waiting!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
HW/SW/CW/GW 346/335/183/150 5'4.25"
Ruby,
Thanks for the much needed hug!!!! I am trying to keep my eye on the prize!!!
More waiting......
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Brenda,
Thank you SO MUCH for the prayers!!!!! I am going to be patient about the hearing......
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
Thank YOU for the prayers!!!!!!
Not necessarily angry, disappointed that is what I feel now. No use in wasting my energy..... After the road I have been traveling for so long, I have learned to be patient.
I WILL KEEP GOING!!!!!!
-Jamie
RNY 2/26/2002 DS 12/29/2011
HW 317 SW 263 BMI 45.1
SW 298 CW 192 BMI 32.9~60% EWL
LW 151 in 2003
TT 4/9/2003
Normal BMI 24.8 is my GOAL!!!
GBP (RNY) 2/26/02 298 lbs, TT 4/9/03 151 lbs, DS 12/29/11
HW 317 SW 263 BMI 45.1/CW 192 BMI 32.9/GW 145 ~ Normal BMI 24.8
**Revision Journey started 3/2009 Approved 12/12/11**
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